Executive summary

The Delivery plan for recovering urgent and emergency care services sets out actions to grow the urgent and emergency care (UEC) workforce and support staff to work flexibly, for the benefit of patients and staff wellbeing. It commits to ‘increase UEC workforce size and improve flexibility’ including ‘introducing more homeworking opportunities for all roles, including helping to spread the technology required’.

In response to the Covid-19 pandemic, many NHS 111 providers worked at pace to pilot homeworking for health advisors. Now, almost all NHS 111 providers continue to offer homeworking to some degree. While it’s common for providers to offer homeworking to NHS 111 clinicians, there is a varied offer for non-clinical staff including health and service advisors.

This document provides non-mandatory guidance and practical advice to help NHS 111 providers further develop their homeworking offer for health advisors. It outlines the benefits of homeworking, highlights possible implications, and offers solutions. Provider homeworking case studies, offering this option can be reviewed case studies.

Homeworking models for health advisors will vary, depending on the needs of the organisation, staff, and patients. This documentation aims to help providers make informed decisions about the best way to develop and adopt their own homeworking model, or scale up where already in place. Please contact the Integrated Urgent Care team for further support: england.integratedurgentcare@nhs.net.

How can health advisor homeworking support NHS 111?

Many providers have reported difficulty in recruiting and retaining health advisors.. Recruitment can also be resource intensive, both in working hours and costs.

Unfilled posts, partnered with high demand, can put increased pressure on health advisors. Fewer staff can result in health advisors taking consecutive calls over long periods, with little to no ‘rest’ between.

There are reported advantages from offering homeworking to staff, benefiting both employees and the organisations. A survey from the Office of National Statistics found that 78% of those working from home across all sectors reported that homeworking improved their work-life balance (Office for National Statistics, 2022).

Similar feedback has been reported from health advisors who already work from home. Shorter shifts without commutes help improve wellbeing and job satisfaction indicating homeworking can help providers improve retention.

Flexibility

Homeworking can offer health advisors more choice over where, when, and how they work. They may be able to work more flexible hours and take on extra shifts at short notice. This can be particularly helpful during peak demand.

Wellbeing

Homeworking can improve staff satisfaction and wellbeing by reducing commuting time and enabling a better work life balance.

The increased sense of trust between employer and employee required for homeworking can foster a more positive working environment and improved relationships.

Employer of choice

Offering homeworking opportunities to staff can be advantageous for businesses looking to recruit. NHS 111 may become a more attractive place to work compared to other organisations which do not offer homeworking as an option. Homeworking may be an incentive for staff with personal commitments who may otherwise struggle to physically attend a contact centre.

Increased recruitment pool

By offering the choice of homeworking to prospective health advisors, providers could open opportunities to people who may not otherwise be able to travel to a contact centre to work. Personal responsibilities, poor health (but still fit to work) and commuting distance are some examples of potential barriers to staff working for NHS 111. Homeworking can break down commuting barriers and extend the recruitment window beyond the geographical location of the contact centre, both regionally and nationally. Anyone working from home due to poor health must be legally fit to work and the appropriate assessment and sign-off completed.

Cost savings

Although homeworking may include some initial costs to the provider, such as supplying IT equipment, consideration should be given to the potential long-term savings from improved retention and reduced recruitment activity that offering homeworking may generate (see: costs). In November 2022, an NHS 111 provider reported operating costs of homeworking was 15% lower than within a contact centre, plus micro-rostering, reduced attrition, and better productivity.

Accessibility, equality and inclusivity

In addition to increasing the recruitment pool, offering homeworking can help to tackle inequalities by creating a more inclusive environment for staff who may have accessibility needs. A survey of staff with a disability who worked from home during the Covid-19 pandemic found that 54% said they felt they would benefit from being able to work from home after the Covid-19 pandemic restrictions were lifted (Unison, 2022). Some respondents reported that homeworking helped them to manage their impairments better whilst working, and removed barriers associated with commuting with some conditions (Unison, 2022). A survey by Lancaster University of homeworkers with a disability found 70% of correspondents said if their employer did not allow homeworking, it would negatively impact their physical and/or mental health.

Business continuity

As demonstrated in the Covid-19 pandemic, homeworking can offer operational protection in times of unexpected or adverse events which may severely disrupt business. Offering homeworking to suitable health advisors can support business continuity where contact centre working may not be possible. Successful business continuity helps to respond to the incident at hand whilst maintaining patient safety and optimal performance (see: business continuity).

Are there implications to homeworking?

Non-clinical triage in NHS 111 requires skilled members of staff with the appropriate level of support and training, to ensure that both patients and staff are safe. There can be implications to homeworking if it isn’t properly prepared for, implemented, and managed effectively.

Isolation and welfare

Remote working may contribute to feelings of isolation in homeworkers due to lack of in-person interaction.

In NHS 111 triage, where there can be emotionally challenging calls or difficult conversations, it is important that staff feel supported and have access to pastoral support (see: support and wellbeing).

Appropriate and timely access to virtual support is a fundamental building block in local operational design. In case of more complex or serious calls, health advisors must be able to seek immediate assistance from more senior staff or clinicians.

Risk and safety

Non-clinical remote workers must feel confident to utilise the technology and remote support available to work as safely and efficiently as they would in a contact centre. Staff who do not feel that they are able to work in this way risk safety for themselves and patients. Clinical safety is paramount and must replicate the same standards as a contact centre environment. If a remote worker is left without the appropriate level of clinical and managerial support, there is a risk of potentially serious mistakes and harm to patients (see: IT and technology).

Home environment

Remote working requires a secure, quiet area where confidential calls can take place without disturbance. There are some domestic environments, such as houses of multiple occupancy or where there are caring responsibilities, where extra consideration must be taken to ensure that the remote working area is suitable and safe. If the remote working environment is not appropriately checked and deemed suitable, then there could be a risk to patient confidentiality and safety (see: home environment).

Productivity

Although homeworking can lead to increased levels of productivity in individuals, there is also a risk that productivity decreases, if not carefully monitored and reviewed. Providers can utilise tools to enable them to identify where productivity is challenged in individuals, such as an Intelligent Data Tool (IDT). Issues with productivity should be approached in a supportive manner and provide the health advisor has with resources and training to address issues where appropriate.

Homeworkers need to have at least the same level of audit and performance management as those working in a contact centre (see: performance monitoring).

What do I need to consider when implementing homeworking?

To successfully implement homeworking for health advisors, remote working must replicate the working practices, practical arrangements, safety and support of a contact centre setting. Unlike other sectors and organisations offering homeworking, particular consideration should be made to the skilled and often challenging work which health advisors undertake. The following section covers eight areas which NHS 111 providers must consider and develop as part of any non-clinical homeworking offer.

NHS Pathways and training

NHS Pathways enables safe, consistent NHS 111 triage. With the appropriate governance and technology in place, this safe triage can be delivered by a health advisor working remotely. Health advisors must be in tier 2 audit to be eligible to work from home (accurate as of November 2023).

The NHS Pathways infrastructure has been developed so that it can support and enable homeworking, whilst supporting safe patient care. This enables:

• delivery of remote training
• flexibility of training timelines to support part-time or out of hours training
• homeworking for all system users in a formal auditing role
• homeworking for all service advisors without the need for any face-to-face contact, from ‘day-one’
• remote clinical support
• extended return to practice for up to 3 years.

We support and encourage pilot proposals to test and adapt the licence based on evidence, to ensure the proposed changes are clinically safe and appropriate for all providers. There is much discretion within the licence for providers to manage their staff and competence, with new iterations and updates occurring regularly.

For example, recent iterations to the NHS Pathways provider licence include:

• more provider discretion to move staff into tier 2 audit which enables homeworking
• more streamlined audit for competency sign-off/remote working for service advisors
• reduced common learning within the onboarding period, which reduces training time
• simplified and streamline audit framework
• remote delivery of all core training and workshops
• flexible training timeframes
• more discretion for providers to determine competence of staff returning from a break in practice up to 3 years
• maximum of 1 mandatory training day for release updates, reduced from 2 days
• increased trainer to trainee ratio of one trainer to up to twelve participants.

Home environment

The remote working environment for health advisors working at home must reflect the controlled environment of a contact centre. This is to ensure safety and confidentiality for patients and callers and access to immediate support for health advisors, should they need it. To achieve this, the following must be ensured:

Remote working area

• Quiet: The working area should be free of noise disturbances which could disrupt the call or distract the health advisor.
• Private: The area should be sound proofed to ensure that other people in the home cannot overhear the conversation. It should be free of potential domestic disruptions such as family members entering the room.
• Comfortable: The workstation should be set up to ensure comfort throughout the shift, including enough physical space, adequate light source and temperature control.
• Display Screen Equipment (DSE) assessment: Homeworkers must complete an assessment of their workstation and DSE in line with the most current legal guidelines and regulations.

Providers must receive adequate assurance from the health advisor, both before and during the commencement of homeworking, that these criteria are met. This could come directly from the health advisor in the form of signing agreements and confirmation documentation and/or photographic evidence. Alternatively, the provider may wish to consider a physical inspection. Health advisors should also consider how working from home will affect any home insurance policies and take appropriate actions if required.

Remote working equipment

The remote workstation should include all the necessary office equipment for the health advisor to effectively carry out their work at home. This must reflect at least the same equipment as provided at workstations in the contact centre. Examples of this include, but are not limited to:

• desk
• height adjustable ergonomic chair
• optional: confidential waste disposal (if applicable to provider policy) (see: security)
• optional: stationary (if applicable to provider policy) (see: security)

Remote working equipment can be supplied by the provider, or the homeworker. Providers must ensure that any equipment provided is safety compliant, as they would in a contact centre. If the equipment is supplied by the homeworker, they must provide assurance to the provider that it is safety compliant. Training and information must be provided to health advisor homeworkers about health and safety relating to DSE. This should include equipment set-up guidance.

IT and technology

IT and technology can be used to support remote supervision and enable health advisors to carry out their work. It is essential that safety and security is maintained for all IT and technology utilised for homeworkers to the same extent as that in a contact centre.

Hardware

Providers may provide IT hardware, or homeworkers can use their own, if it meets essential security and confidentiality criteria. Examples of IT equipment, reflecting that used in a contact-centre, include (but are not limited to):

• laptop
• monitor
• mouse
• keyboard
• cables

Software

Each NHS 111 provider will have selected software for telephone triage. The provider must decide whether this can be adapted for remote working, or if new software is required. Below are some examples of the technical functions required for homeworking and examples of software packages used by providers currently offering homeworking:

Specification and testing

Providers must ensure that all IT hardware meets the specifications required for health advisors to carry out their work effectively.

Laptop

Below are suggestions of a laptop specification to consider and examples of criteria which some providers have been using:

Providers must decide whether to supply laptop devices to health advisors working from home, or to employ a BYOD (bring your own device) policy. It is essential that the device has essential security software to ensure there is no data at rest and an inability to transpose data on another device. We would recommend supplying laptops as this allows much more robust quality, safeguarding and security control. Laptops should also have adequate antivirus software.

Internet

Homeworking health advisors are responsible for providing their own internet packages. Assurance of internet speed and bandwidth should be provided by the health advisor Internet/broadband contract length and assurance of continued supply should be considered when assessing eligibility for homeworking. It should also be considered how speed and bandwidth will be affected by peak times or with other internet users in the household. A speed test should be considered at peak times, both operationally for NHS 111 and general social browsing hours.

Below are suggestions of internet specification to consider and examples of criteria which some providers have been using:

Security

Providers must ensure that all IT hardware and software is secure and protected from any possible data breaches (see: IT and technology). The homeworking environment must also be secure and free from potential confidentiality breaches (see: homeworking environment).

Confidentiality and data protection

Providers must make sure they have policies in place to protect patient data and confidentiality in homeworking settings. Providers must decide whether to provide confidential waste disposal methods for health advisors working from home or disallow physical note taking completely. Examples of how this could be implemented include:

Waste disposal policy:

• paper shredders for health advisors to dispose confidential notes
• signing of confidentiality agreements and consent forms

No paper policy:

• ability to take notes ‘virtually’ which are then deleted after each shift
• removing ability to print from laptop (through remote desktop build)

Health advisors working from home must undergo the same mandatory data security and data protection training as those working in a contact centre. Providers may wish to expand their confidential waste policy to include homeworking practices.

Information governance

Health advisors working from home must be aware and have access to the provider information governance policies and undergo the same information governance agreement and training as those working in a contact centre.

Eligibility criteria

For a health advisor to work from home, they must be in tier 2 audit and have successfully completed all initial training including core module 2 (see ‘Pathways’). Providing these two requirements are met, it is at the discretion of the provider to determine when the health advisor is deemed as eligible to work from home. It is also at their discretion whether the health advisor works fully from home or has a hybrid arrangement.

It is advised that providers produce a health advisor homeworker person specification check list, to ensure that both the organisation and the health advisor feel safe, confident, and comfortable with a homeworking arrangement. This should be reviewed regularly. Below are some examples of person-specification criteria which current providers are setting for their homeworking eligibility:

• Training
  • Has the health advisor passed core module 1 & 2, and completed all mandatory consolidated learning and all relevant release update training?
  • Has the provider completed all other training relevant and necessary for a homeworking arrangement (locally determined).
• Audit
  • Does the health advisor meet the eligibility criteria for working within tier 2 audit?
  • Is the health advisor consistently performing safely and effectively?
  • Is the health advisor free from persistent and/or significant performance issues? (See: performance monitoring).
  • Is the health advisor free from involvement in complaints/SUIs if their practice is deemed to be a possible contributory factor? factor?
• Performance and conduct
  • Does the health advisor have exemplary performance and conduct history? (See: performance monitoring).
• Attendance
  • Some providers report high attendance levels as part of their eligibility criteria. Does the health advisor meet the minimum criteria as set out by the provider to work from home?
• Technical skills
  • Is the health advisor compliant with all IT training?
  • Are they confident with IT equipment and troubleshooting basic IT issues where appropriate?

Depending on local policies and procedures, providers may also wish to consider:

• Probation
  • Has the health advisor passed the organisational probation period?
• Experience
  • What level of experience do you require health advisor homeworkers to have before they are eligible to work from home? This could include number of shifts and continuous time in post (months).
• Local governance
  • Is the health advisor aware of and have access to all information governance, data protection, and other relevant policies?

Alongside the person specification, providers must also ensure that the health advisor has passed all homeworking environment checks (see: home environment). These criteria and checks should be reviewed on a regular basis.

Performance monitoring

Health advisors working from home must have the same performance and monitoring standards as those working from a contact centre. IT and technology can be utilised to support this remotely.

Performance and conduct

Providers should ensure that there is a set standard for performance of health advisors working from home, including minimum standards on productivity and conduct. Managers should conduct regular performance reviews with health advisors working from home. Low productivity or issues with performance should be approached in the first instance in a supportive manner, to explore whether additional support or training is needed. Health advisors may need additional support working remotely (see: support and wellbeing).

Audit

Providers must ensure that health advisors working from home are audited to at least the same level as contact centre staff, following the requirements of the NHS Pathways provider licence audit framework. This is a supportive opportunity to ensure health advisors are working to the highest standard. Audit can be delivered in the following ways:

• live auditing: Auditor can use audit systems or screen sharing technology to observe calls as they take place
• retrospective auditing: Auditing selection of recorded calls for analysis.

For hybrid workers, it is recommended that audits are completed for both contact centre work and homeworking to ensure all-round performance.

Providers must reserve the right to remove homeworking from health advisors if issues with their performance continue despite intervention. They must reserve the right to remove homeworking immediately if patient or staff safety is at risk.

Costs

Some providers who offer homeworking to health advisors report some costs associated with setting up and implementing hybrid working. The extent to which there are costs involved depends on the homeworking model the provider develops, and what costs are expected to be covered by the health advisor. Costs to the provider may include:

• homeworking office equipment and hardware
• homeworking technology and software
• commuting costs if required to attend training/face to face meetings (non-hybrid)
• resources to provide additional training and eligibility tests/monitoring.

Costs to the health advisor may include:

• increased energy bills (gas, water, electricity)
• internet package adequate bandwidth and speed (including at peak times).

However, any associated costs with homeworking should be considered against cost off-sets and longer-term savings from working remotely. Providers should also consider the cost against social value, such as increased staff wellbeing and satisfaction at work.

Support and wellbeing

Health advisors working from home should have access to the same health and wellbeing offer as health advisors working from a contact-centre. Examples of this may include online resources, mental health first aiders and support lines. Where these are normally face-to-face in a contact centre, amendments should be made for homeworkers to access resources remotely.

However, additional consideration should be given to health advisors working remotely, who are more at risk of isolation. Additional steps must be taken to include them in the contact centre community and ensure equal opportunities for all health advisors regardless of working location. They must be included and kept up to date with any changes in the contact centre. Examples of considerations for homeworking staff include:

• risk assessment: Before homeworking commences, consider a risk assessment with the health advisor to consider how they might feel working remotely for extended periods of time. Consider what additional support they may require as an individual and discuss any concerns which either party may have
• stay connected: Make sure that the homeworker can stay in touch with colleagues and managers consistently throughout their shift. This may include live chat with other colleagues and inclusion in social events
• buddy system: Some providers pair homeworking staff as part of a buddy system, to keep in touch throughout the day and help each other with any issues
• return to contact centre: For hybrid workers, ensure that the health advisor has a choice in where they work, and if they wish to discontinue homeworking, have continuity plans which would allow them to return to the contact centre
• check-ins: Providers should host regular check-ins with the health advisor, to review their wellbeing and confirm that homeworking is still effective for them
• support: Homeworkers should be aware of how and where to escalate concerns, and understand what resources are available in a crisis. They should have access to the shift manager and incident de-briefers remotely
• development and training: Homeworkers should have the same access to mandatory training as those working in a contact-centre. For additional development opportunities, a remote offer should be considered where possible.

Business continuity

Homeworking can serve as a business continuity solution, i.e., if the contact centre is closed, or staff are unable to travel. Providers must also consider how homeworking will fit into existing business continuity plans, for example, if there is a technical infrastructure issue or large-scale disruption to the network. Consideration should be given for local policies if site attendance is required. Providers must also consider how to manage and divert demand in the case that the homeworker is unexpectedly absent from work. Examples of this may include:

• domestic incidents
• remote IT equipment failure
• power cut-off.

Providers must ensure lines of communication with the homeworker dealing with an incident and ensure that plans are in place to ensure business continuity. Examples to consider include:

• risk assessment into likelihood of domestic incidents and agreed plan for the provider to be notified immediately and calls diverted
• consideration for power sources to devices in response to a significant power-cut
• consideration for access to internet connection, should broadband be unexpectedly cut off
• ensuring that both the provider and IT service are immediately made aware of IT equipment failure, and back-ups provided where appropriate.

Case studies

‘NHS 111 provider case studies – health advisor homeworking’ includes four case studies of providers offering homeworking to health advisors. It includes detail on how their homeworking model works in practice, challenges faced, and lessons learned. The aim of this document is to provide examples of successful homeworking which NHS 111 providers can refer to when developing their own homeworking model for health advisors.

Useful documents

6 simple tips to tackle working from home – Ideas and tips for homeworkers to feel connected and productive working from home.

About NHS Pathways – Information about NHS Pathways

Delivery Plan for Recovering Urgent and Emergency Care Services (January 2023) – Plan setting out actions to support the recovery of urgent and emergency care services across five priority focus areas.

Homeworking hours, rewards, and opportunities in the UK: 2011 to 2020 – Analysis of working from home in the UK between 2011 and 2020, including pay, hours worked, bonuses, promotions etc.

Homeworking: Managing the cyber risks – Help-page to help organisations introducing/scaling up homeworking to avoid cyber-crime.

Homeworking: The basics for employers/employees – Homeworking advice for employers and employees

Integrated Urgent Care Service Specification – Information and specification of Integrated Urgent Care Services for Providers and Commissioners.

The health and safety (display screen equipment) regulations 1992, as amended by the health and safety (miscellaneous amendments) regulations 2002 – Detailed guidance and legislation on display screen equipment regulations in the workplace in England.

Working from home and hybrid working – homeworking advice for employers and employees.

Publication reference: PRN00732